Use of genomic testing and ketogenic compounds for treatment of reduced cognitive function

ABSTRACT

This invention relates to methods of using genotyping to select patients for treatment with compounds capable of elevating ketone body concentrations in amounts effective to treat reduced neuronal metabolism associated with reduced neuronal metabolism, for example Alzheimer&#39;s disease.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a 35 USC §371 of PCT Application Serial No.PCT/US2008/071817, filed Jul. 31, 2008, currently pending, entitled “Useof Genomic Testing and Ketogenic Compounds for Treatment of ReducedCognitive Function,” which claims priority to U.S. Provisional PatentApplication No. 60/953,074, filed Jul. 31, 2007, entitled “Genomictesting in Alzheimer's disease and other diseases associated withreduced neuronal metabolism,” which are each incorporated herein intheir entirety by reference.

FIELD OF THE INVENTION

This invention relates to methods of selecting patients for a treatmentfor reduced cognitive function, wherein the treatment comprisesadministering to the patient at least one compound capable of elevatingketone body concentrations in an amount effective for the treatment ofreduced cognitive function. Reduced cognitive function is associatedwith Age-Associated Memory Impairment (AAMI), Alzheimer's Disease (AD),Parkinson's Disease, Friedreich's Ataxia (FRDA), GLUT1-deficientEpilepsy, Leprechaunism, and Rabson-Mendenhall Syndrome, CoronaryArterial Bypass Graft (CABG) dementia, anesthesia-induced memory loss,Huntington's Disease, and many others.

Incorporated by reference herein in its entirety is the Sequence Listingco-submitted with the instant application, entitled “SeqListingST25.txt”, created Jul. 31, 2008, size of 11.7 kilobytes.

BACKGROUND OF THE INVENTION

Alzheimer's Disease

Alzheimer's disease (AD) is a progressive neurodegenerative disorderthat primarily affects the elderly. In 1984, Blass and Zemcov (Blass andZemcov 1984) proposed that AD resulted from a decreased metabolic ratein sub-populations of cholinergic neurons. Measurements of cerebralglucose metabolism indicate that glucose metabolism is reduced 20-40% inAD resulting in critically low levels of ATP.

Attempts to compensate for reduced cerebral metabolic rates in AD havemet with some success. Elevation of serum ketone body levels in ADpatients raises cognitive scores (Reger, Henderson et al. 2004) and USP.

Parkinson Disease (PD)

Parkinson's disease (PD) is a progressive neurodegenerative disorderthat is the second most common neurodegenerative disease afterAlzheimer's disease. The estimated prevalence of PD is 0.3 percent inthe general U.S. population and a prevalence of 4 to 5 percent in thoseolder than 85 years. PD is characterized by motor abnormalities,including tremors, muscle stiffness, lack of voluntary movements, andpostural instability. A primary neuropathological feature of PD is theloss of dopaminergic neurons in the substantia nigra pars compacta(SNpc) and the presence of eosinophilic intracytoplasmic inclusions(Lewy bodies) in the residual dopaminergic neurons.

Therefore, there exists a need for more effective treatments for PD andin particular for treatments that are neuroprotective.

While the cause of sporadic PD is uncertain, several lines of evidencesuggest that defects in oxidative phosphorylation may contribute to itspathogenesis. For example, 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine(MPTP), blocks complex I (NADH-ubiquinone oxidoreductase) of themitochondrial electron transport chain, and causes the loss ofdopaminergic neurons and the typical symptoms of PD. Reduction incomplex I activity has also been reported in PD tissues. This defect isnot confined only to the brain but has also been found in platelets fromPD patients.

D-beta-Hydroxybutyrate (BHB) is a ketone body produced by hepatocytesand, to a lesser extent, by astrocytes. BHB acts as an alternativesource of energy in the brain when glucose supply is limited such asduring starvation. BHB has been found to protect from MPTP-relatedcomplex I inhibition, by enhancing oxidative phosphorylation (Tieu,2003).

Friedreich's Ataxia (FRDA)

FRDA is a recessive disease characterized by progressive ataxia,hypertrophic cardiomyopathy, early onset of insulin-resistant diabetes,invalidism, and premature death. FRDA is a genetic disorder caused by adeficiency of frataxin, a 210 amino acid nuclear-encoded mitochondrialprotein. Low levels of the protein are due to the expansion of anintronic GAA repeat, leading to decreased mRNA levels. FRDA patientsshow a decrease in the activity of the mitochondrial enzyme aconitase.Aconitase is responsible for conversion of citrate to isocitrate, thefirst step in the Krebs (also known as the citric acid or TCA cycle).Deficiency of frataxin in human patients is thought to lead primarily todefects in the TCA cycle.

Recent work shows that elevation of blood ketone bodies, a normalresponse to fasting, can increase mitochondrial citrate and isocitratelevels, thus overcoming the block in aconitase found in FRDA. A ketonebody-based therapy could provide an effective treatment for this groupof patients.

GLUT1-deficient Epilepsy

GLUT1-deficient Epilepsy is characterized by infantile seizures, delayeddevelopment, and acquired microcephaly with mental retardation.GLUT1-deficient epilepsy results from several types of mutation in thegene of GLUT1. Glucose transporter 1 (GLUT1) is the major proteinresponsible for the transport of glucose from bloodstream into thebrain. Under standard dietary conditions, the brain is almost entirelydependent upon blood glucose for energy. However, under somecircumstances, such as starvation, ketone bodies can provide a source ofenergy different from glucose. Ketone bodies do not rely on GLUT1 fortransport into the brain and therefore may provide energy inGLUT1-deficient syndrome. Ketone body therapy may therefore become apractical method for lifelong treatment of these patients.

Leprechaunism and Rabson-Mendenhall Syndrome

Leprechaunism and Rabson-Mendenhall syndrome are rare diseasecharacterized by insulin resistance, persistent hyperglycemia andretardation of growth. Subjects rarely survive past 20 years of age.These syndromes result from mutations in the insulin receptor gene,which lower the receptors affinity for insulin. The current treatmentconsists of administration of increasing doses of insulin (up to severalthousand units per day). This treatment yields only weak results due tothe poor binding of insulin to its receptor. Ketone bodies have beenshown to mimic the effects of insulin's stimulation of the PDHmultienzyme complex, thereby increasing the Krebs TCA cycle metabolitelevels, increasing the energy output in the form of ATP, and enhancingmetabolic efficiency. A ketone-rich, or ketogenic diet may prove aneffective treatment of these conditions.

Age-Associated Memory Impairment

Aging causes deterioration of various aspects of physiology in normaladults, including memory performance. Such age related declines incognitive performance have long been recognized by medicalpractitioners. Impairment of memory performance in the elderly has beendetected in several standard memory tests, including the Wechsler MemoryScale (WMS) and immediate and delayed Visual Reproduction Test (Trahanet al. Neuropsychology, 1988 19(3) p. 173-89), the Rey Auditory VerbalLearning Test (RAVLT) (Ivnik, R. J. et al. Psychological Assessment: AJournal of Consulting and Clinical Psychology, 1990 (2): p. 304-312) andothers (for review see Larrabee and Crook, Int. Psychogeriatr, 19946(1): p. 95-104.

Other Diseases and Syndromes

A great number of other diseases and syndromes are associated withdecreased metabolism. Such conditions include Coronary Arterial BypassGraft (CABG) dementia, anesthesia induced memory loss, Huntington'sdisease and many other. It is apparent that a metabolic intervention mayaid people suffering from such afflictions.

There is thus a need in the art to develop compositions and methods forthe treatment and/or prevention of cognitive impairment, particularly inaging or geriatric mammals such as humans.

Various publications, including patents, published applications,technical articles and scholarly articles are cited throughout thespecification. Each of these cited publications is incorporated byreference herein, in its entirety. A partial list of those patents andapplications referenced herein include, for example, U.S. Ser. No.60/953,074, “Genomic testing in Alzheimer's disease and other diseasesassociated with reduced neuronal metabolism”, filed Jul. 31, 2007; U.S.Ser. No. 60/917,886, “Inhibitors of Acetyl-CoA Carboxylase for Treatmentof Hypometabolism”, filed May 14, 2007; U.S. Ser. No. 11/123,706,“Method for Reducing Levels of Disease Associated Proteins”, filed May3, 2005; U.S. Ser. No. 11/424,429, “Method To Reduce Oxidative DamageAnd Improve Mitochondrial Efficiency”, filed Jun. 15, 2006; U.S. Ser.No. 10/546,976, “Novel-Chemical Entities and Methods for their Use inTreatment of Metabolic Disorders”, filed Aug. 25, 2005; U.S. Ser. No.09/845,741, filed May 1, 2001; U.S. Ser. No. 10/152,147, filed Dec. 28,2004, now U.S. Pat. No. 6,835,750; U.S. Ser. No. 11/021,920, filed Dec.22, 2004; U.S. Ser. No. 11/331,673, filed Jan. 13, 2006; U.S. Ser. No.11/611,114, filed Dec. 14, 2006; and U.S. Ser. No. 11/771,431, filedJun. 29, 2007.

SUMMARY OF THE INVENTION

In one embodiment, the invention comprises a method of selecting apatient having, or at risk of having reduced cognitive function causedby reduced neuronal metabolism, determining in the patient the presenceof at least one of the specific genotypes including: heterozygosity forC/T for Insulin Degrading Enzyme (IDE) rs2551101 at relevant portionshown by SEQ ID NO:3, absence of homozygosity for C/C of IDE rs2551101at relevant portion shown by SEQ ID NO:3, heterozygosity for A/C ofApolipoprotein E (APOE) rs405509 at relevant portion shown by SEQ IDNO:21, heterozygosity for G/A of Butyrylcholine esterase (BUCHE)rs1803274 at relevant portion shown by SEQ ID NO:18, homozygosity foradenine of Insulin-like Growth Factor Receptor precursor (IGF1R)rs2229765 at relevant portion shown by SEQ ID NO:6, homozygosity forthymine of Interleukin-1 beta (IL1B) rs1143627 at relevant portion shownby SEQ ID NO:9, homozygosity for cytosine of IL rs16944 at relevantportion shown by SEQ ID NO:10, homozygosity for cytosine of Low-densityLipoprotein Receptor (LDLR) rs2738447 at relevant portion shown by SEQID NO:24, homozygosity for guanine of LDLR rs7259278 at relevant portionshown by SEQ ID NO:25, and homozygosity for cytosine of LDLR rs1799898at relevant portion shown by SEQ ID NO:15; and selecting a patienthaving at least one of the specific genotypes for treatment, wherein thetreatment comprises administering to the patient at least one compoundcapable of elevating ketone body concentrations in an amount effectivefor the treatment of or prevention of reduced cognitive function causedby reduced neuronal metabolism.

In another embodiment, the present invention includes a method oftreatment for reduced cognitive function caused by reduced neuronalmetabolism. This method may include the steps of selecting a patienthaving, or at risk of reduced cognitive function caused by reducedneuronal metabolism and determining in the patient the presence of atleast one of the specific genotypes including: heterozygosity for C/Tfor Insulin Degrading Enzyme (IDE) rs2551101 at relevant portion shownby SEQ ID NO:3, absence of homozygosity for C/C of IDE rs2551101 atrelevant portion shown by SEQ ID NO:3, heterozygosity for A/C ofApolipoprotein E (APOE) rs405509 at relevant portion shown by SEQ IDNO:21, heterozygosity for G/A of Butyrylcholine esterase (BUCHE)rs1803274 at relevant portion shown by SEQ ID NO:18, homozygosity foradenine of Insulin-like Growth Factor Receptor precursor (IGF1R)rs2229765 at relevant portion shown by SEQ ID NO:6, homozygosity forthymine of Interleukin-1 beta (IL1B) rs1143627 at relevant portion shownby SEQ ID NO:9, homozygosity for cytosine of IL1B rs16944 at relevantportion shown by SEQ ID NO:10, homozygosity for cytosine of Low-densityLipoprotein Receptor (LDLR) rs2738447 at relevant portion shown by SEQID NO:24, homozygosity for guanine of LDLR rs7259278 at relevant portionshown by SEQ ID NO:25, and homozygosity for cytosine of LDLR rs1799898at relevant portion shown by SEQ ID NO:15. The method may furtherinclude administering to the patient having at least one of the specificgenotypes at least one compound capable of elevating ketone bodyconcentrations in an amount effective for the treatment of or preventionof reduced cognitive function caused by reduced neuronal metabolism.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 demonstrates interaction between IDE and APOE polymorphisms onTreatment-induced ADAS-Cog change.

DETAILED DESCRIPTION OF THE INVENTION

It is the novel insight of this invention that particular polymorphismsmay be useful for selecting patients for treatment for reduced cognitivefunction caused by reduced neuronal metabolism, wherein the treatmentcomprises administering to patients at least one compound capable ofelevating ketone body concentrations. Particular polymorphisms areassociated with “responders,” i.e., patient populations in whichtreatment methods comprising administration of compounds capable ofincreasing ketone body concentration are associated with efficacy. Alsoincluded in the present invention are methods to treat patients havingreduced cognitive functions which include testing the patient forparticular polymorphisms and selecting a patient for treatment based onthe presence of the particular polymorphism.

In one embodiment, the invention comprises a method of selecting apatient having, or at risk of having reduced cognitive function causedby reduced neuronal metabolism, determining in the patient the presenceof at least one of the specific genotypes including: heterozygosity forC/T for Insulin Degrading Enzyme (IDE) rs2551101 at relevant portionshown by SEQ ID NO:3, absence of homozygosity for C/C of IDE rs2551101at relevant portion shown by SEQ ID NO:3, heterozygosity for A/C ofApolipoprotein E (APOE) rs405509 at relevant portion shown by SEQ IDNO:21, heterozygosity for G/A of Butyrylcholine esterase (BUCHE)rs1803274 at relevant portion shown by SEQ ID NO:18, homozygosity foradenine of Insulin-like Growth Factor Receptor precursor (IGF1R)rs2229765 at relevant portion shown by SEQ ID NO:6, homozygosity forthymine of Interleukin-1 beta (IL1B) rs1143627 at relevant portion shownby SEQ ID NO:9, homozygosity for cytosine of IL1B rs16944 at relevantportion shown by SEQ ID NO:10, homozygosity for cytosine of Low-densityLipoprotein Receptor (LDLR) rs2738447 at relevant portion shown by SEQID NO:24, homozygosity for guanine of LDLR rs7259278 at relevant portionshown by SEQ ID NO:25, and homozygosity for cytosine of LDLR rs1799898at relevant portion shown by SEQ ID NO:15; and selecting a patienthaving at least one of the specific genotypes for treatment, wherein thetreatment comprises administering to the patient at least one compoundcapable of elevating ketone body concentrations in an amount effectivefor the treatment of or prevention of reduced cognitive function causedby reduced neuronal metabolism.

In another embodiment, the present invention includes a method oftreatment for reduced cognitive function caused by reduced neuronalmetabolism. This method may include the steps of selecting a patienthaving, or at risk of reduced cognitive function caused by reducedneuronal metabolism and determining in the patient the presence of atleast one of the specific genotypes including: heterozygosity for C/Tfor Insulin Degrading Enzyme (IDE) rs2551101 at relevant portion shownby SEQ ID NO:3, absence of homozygosity for C/C of IDE rs2551101 atrelevant portion shown by SEQ ID NO:3, heterozygosity for A/C ofApolipoprotein E (APOE) rs405509 at relevant portion shown by SEQ IDNO:21, heterozygosity for G/A of Butyrylcholine esterase (BUCHE)rs1803274 at relevant portion shown by SEQ ID NO:18, homozygosity foradenine of Insulin-like Growth Factor Receptor precursor (IGF1R)rs2229765 at relevant portion shown by SEQ ID NO:6, homozygosity forthymine of Interleukin-1 beta (IL1B) rs1143627 at relevant portion shownby SEQ ID NO:9, homozygosity for cytosine of IL1B rs16944 at relevantportion shown by SEQ ID NO:10, homozygosity for cytosine of Low-densityLipoprotein Receptor (LDLR) rs2738447 at relevant portion shown by SEQID NO:24, homozygosity for guanine of LDLR rs7259278 at relevant portionshown by SEQ ID NO:25, and homozygosity for cytosine of LDLR rs1799898at relevant portion shown by SEQ ID NO:15. The method may furtherinclude administering to the patient having at least one of the specificgenotypes at least one compound capable of elevating ketone bodyconcentrations in an amount effective for the treatment of or preventionof reduced cognitive function caused by reduced neuronal metabolism.

Testing the patient for a specific genotype may be done by methodscommonly known in the art. Specifically, based on the particulargenotype of interest, it is routine for one of skill to chooseappropriate primers. Numerous online tools exist for guidance in primerdesign, such as, for example, the algorithm Primer3 (v. 0.4.0) whichallows choosing appropriate primers for detecting a targeted DNAsequence, available at <frodo.wi.mit.edu>.

Once primers are selected, DNA extraction may be performed by extractinggenomic DNA from EDTA anti-coagulated venous blood, which may beaccomplished by such art-known methods such as QIA-amp Blood-DNAmini-reagent set (Qiagen) according to the manufacturer's instructions.To detect specific polymorphisms, appropriately designed primer sets maybe used to amplify regions containing the polymorphism of interest,using methods known in the art. Genotyping may be ascertained throughdirect sequencing of PCR products using art known products such as theABI PRISM BigDye Terminator Cycle Sequencing Ready Reaction Kit and ABIPRISM 377 DNA Sequencer (Applied Biosystems, Foster City, Calif., USA).

In one embodiment, the genotype comprises heterozygosity (C/T) for SNPIDE rs2251101 also known as IDE_(—)7 of Insulin Degrading Enzyme (IDE).In another embodiment, the genotype comprises absence of homozygosityfor C/C for SNP rs2251101 also known as IDE_(—)7 of Insulin DegradingEnzyme (IDE). IDE (HGNC Symbol ID). This gene is a member of the humanCCDS set: CCDS7421. Ensembl Gene ID: ENSG00000119912. Genomic Location:This gene can be found on Chromosome 10 at location94,201,421-94,323,813. The start of this gene is located in ContigAL356128.27.1.191935. Description: Insulin-degrading enzyme (EC3.4.24.56) (Insulysin) (Insulinase) (Insulin protease). Source:Uniprot/SWISSPROT P14735. SEQ ID NO:3 shows a selected portion of thisgene identifying polymorphisms of SNP rs2251101.

In another embodiment, the genotype comprises homozygosity for A forrs2229765 of insulin-like growth factor 1 receptor precursor (IGFR-1).IGF1R (HGNC Symbol ID). This gene is a member of the human CCDS set:CCDS10378. Ensembl Gene ID: ENSG00000140443. Genomic Location: This genecan be found on Chromosome 15 at location 97,010,302-97,319,034. Thestart of this gene is located in Contig AC118658.4.1.168727. DescriptionInsulin-like growth factor 1 receptor precursor (EC 2.7.10.1)(Insulin-like growth factor I receptor) (IGF-I receptor) (CD221 antigen)[Contains: Insulin-like growth factor 1 receptor alpha chain;Insulin-like growth factor 1 receptor beta chain]. Source:Uniprot/SWISSPROT P08069. SEQ ID NO:6 shows a selected portion of thisgene identifying polymorphisms of SNP rs2229765.

In another embodiment, the genotype is homozygosity for T at IL1Brs1143627. In another embodiment, the genotype is homozygosity for C atIL1B rs 16944. IL1B(HGNC Symbol ID. This gene is a member of human CCDSset CCDS2102 with Ensembl Gene ID ENSG00000125538. This gene can befound on Chromosome 2 at location 113,303,808-113310,827. The start ofthis gene is located in Contig AC079753.7.1.154214. Description isInterleukin-1 beta precursor (IL-1 beta) (Catabolin). Source:Uniprot/SWISSPROT P01584. Rs1143627 is a C/T substitution and SEQ IDNO:9 shows a selected portion of this gene identifying placement of thisSNP. rs16944 (dbSNP125) is an A/G substitution and SEQ ID NO:10 shows aselected portion of this gene identifying polymorphisms of this SNP.

In another embodiment, the genotype is homozygosity for C at LDLRrs2738447. This gene is a member of the human CCDS set: CCDS12254 withan Ensembl Gene ID ensg00000130164. This gene can be found on Chromosome19 at location 11,061,155-11,103,838 and the start of this gene islocated in Contig AC011485.6.1.128618. Description is Low-densitylipoprotein receptor precursor (LDL receptor). Source: Uniprot/SWISSPROTP01130. SEQ ID NO:24 shows a selected portion of this gene identifyingpolymorphisms of this SNP.

In another embodiment, the genotype is homozygosity for G at LDLRrs7259278. This gene is a member of the human CCDS set: CCDS12254 withan Ensembl Gene ID ensg00000130164. This gene can be found on Chromosome19 at location 11,061,155-11,103,838 and the start of this gene islocated in Contig AC011485.6.1.128618. Description is Low-densitylipoprotein receptor precursor (LDL receptor). Source: Uniprot/SWISSPROTP01130. SEQ ID NO:25 shows a selected portion of this gene identifyingpolymorphisms of this SNP.

In another embodiment, the genotype is homozygosity for C atLDLRrs1799898. LDLR (HGNC Symbol ID). This gene is a member of the humanCCDS set: CCDS12254 with an Ensembl Gene ID ensg00000130164. This genecan be found on Chromosome 19 at location 11,061,155-11,103,838 and thestart of this gene is located in Contig AC011485.6.1.128618. Descriptionis Low-density lipoprotein receptor precursor (LDL receptor). Source:Uniprot/SWISSPROT P01130. SEQ ID NO:15 shows a selected portion of thisgene identifying polymorphisms of SNP rs1799898.

In another embodiment, the genotype is heterozygosity for G/A forButyrylcholine esterase (BUCHE) K variant rs1803274. BCHE (HGNC SymbolID). This gene is a member of the human CCDS set CCDS3198. Ensembl GeneID is ENS00000114200. This gene can be found on Chromosome 3 at location166,973,387-167,037,944. The start of this gene is located in ContigAC009811.14.1.171083. Cholinesterase precursor (EC 3.1.1.8) (Acylcholineacylhydrolase) (Choline esterase II) (Butyrylcholine esterase)(Pseudocholinesterase). Source: Uniprot/SWISSPROT P06276. SEQ ID NO:18shows a selected portion of this gene identifying polymorphisms of SNPrs1803274.

In another embodiment, the genotype is heterozygosity for A/C ofapolipoprotein E (APOE) promoter variant rs405509. Rs405509 is the −219variant and has an A/C allele. APOE (HGNC Symbol ID). This gene is amember of the human CCDS set: CCDS12647. Ensemble Gene ID isENSG00000130203. This gene can be found on Chromosome 19 at location50,100,879-50,104,489. The start of this gene is located in ContigAC011481.4.1.107567. Apolipoprotein E precursor (Apo-E). Source:Uniprot/SWISSPROT P02649. SEQ ID NO:21 shows a selected portion of thisgene identifying polymorphisms of SNP rs405509.

As used herein, reduced neuronal metabolism refers to all possiblemechanisms that could lead to a reduction in neuronal metabolism. Suchmechanisms include, but are not limited to mitochondrial dysfunction,free radical attack, generation of reactive oxygen species (ROS),ROS-induced neuronal apoptosis, defective glucose transport orglycolysis, imbalance in membrane ionic potential, dysfunction incalcium flux, and the like. In another embodiment, the patient has or isat risk of developing disease-related reduced cognitive function causedby reduced neuronal metabolism, for example, reduced cognitive functionassociated with Alzheimer's Disease (AD), Parkinson's Disease,Friedreich's Ataxia (FRDA), GLUT1-deficient Epilepsy, Leprechaunism, andRabson-Mendenhall Syndrome, Coronary Arterial Bypass Graft (CABG)dementia, anesthesia-induced memory loss, Huntington's Disease, and manyothers.

According to the present invention, high blood ketone levels willprovide an energy source for brain cells that have compromised glucosemetabolism, leading to improved performance in cognitive function. Asused herein, “patient” refers to any mammal, including humans that maybenefit from treatment of disease and conditions resulting from reducedneuronal metabolism.

In one embodiment, a compound capable of elevating a ketone bodyconcentrations in the body of a mammal include “medium chaintriglycerides” or “MCT”, referring to any glycerol molecule ester-linkedto three fatty acid molecules, each fatty acid molecule having a carbonchain of 5-12 carbons. MCT may be represented by the following generalformula:

where R1, R2 and R3 are fatty acids having 5-12 carbons in the carbonbackbone esterified to the a glycerol backbone. The structured lipids ofthis invention may be prepared by any process known in the art, such asdirect esterification, rearrangement, fractionation,transesterification, or the like. For example, the lipids may beprepared by the rearrangement of a vegetable oil such as coconut oil.The length and distribution of the chain length may vary depending onthe source oil. For example, MCT containing 1-10% C6, 30-60% C8, 30-60%CIO, 1-10% CIO are commonly derived from palm and coconut oils. MCTcontaining greater than about 95% C8 at R1, R2 and R3 can be made bysemi-synthetic esterification of octanoic acid to glycerin. Such MCTbehave similarly and are encompassed within the term MCT as used herein.

MCT are comprised of fatty acids with chain length between 5-12 carbonsand have been researched extensively. MCT are metabolized differentlyfrom the more common Long Chain Triglycerides (LCT). In particular, whencompared to LCT, MCT are more readily digested to release medium chainfatty acids (MCFA) which exhibit increased rates of portal absorption,and undergo obligate oxidation. MCFA have melting points much lower thanlong chain fatty acids (LCFA), and therefore the MCFA and correspondingMCT are liquid at room temperature. MCFA are smaller and more ionized atphysiological pH compared to LCFA, and hence MCFA are much more solublein aqueous solutions. The small size and decreased hydrophobicity of MCTincreases the rate of digestion and absorption relative to LCT.

When ingested, MCT are first processed by lipases, which cleave thefatty acid chains from the glycerol backbone. Some lipases in thepre-duodenum preferentially hydrolyze MCT over LCT and the released MCFAare then partly absorbed directly by the stomach mucosa. Those MCFAwhich are not absorbed in the stomach are absorbed directly into theportal vein and not packaged into lipoproteins. LCFA derived from normaldietary fat are re-esterified into LCT and packaged into chylomicronsfor transport in the lymph. This greatly slows the metabolism of LCTrelative to MCT. Since blood transports much more rapidly than lymph,MCFA quickly arrive at the liver.

In the liver MCFA undergo obligate oxidation. In the fed state LCFAundergo little oxidation in the liver, due mainly to the inhibitoryeffects of malonyl-CoA. When conditions favor fat storage, malonyl-CoAis produced as an intermediate in lipogenesis. Malonyl-CoAallosterically inhibits carnitine palmitoyltransferase I, and therebyinhibits LCFA transport into the mitochondria. This feedback mechanismprevents futile cycles of lipolysis and lipogenesis. MCFA are, to alarge extent, immune to the regulations that control the oxidation ofLCFA. MCFA enter the mitochondria without the use of carnitinepalmitoyltransferase I, therefore MCFA by-pass this regulatory step andare oxidized regardless of the metabolic state of the organism.Importantly, since MCFA enter the liver rapidly and are quicklyoxidized, large amounts of ketone bodies are readily produced from MCFAand a large oral dose of MCT (roughly 20 mL) will result in sustainedhyperketonemia. It is the novel insight of the inventor that MCT may beadministered outside of the context of a ketogenic diet. Therefore, inthe present invention carbohydrates may be consumed at the same time asMCT.

“Effective amount” refers to an amount of a compound, material, orcomposition, as described herein that is effective to achieve aparticular biological result. Effectiveness for treatment of theaforementioned conditions may be assessed by improved results from atleast one neuropsychological test. These neuropsychological tests areknown in the art and include Clinical Global Impression of Change(CGIC), Rey Auditory Verbal Learning Test (RAVLT), First-Last NamesAssociation Test (FLN), Telephone Dialing Test (TDT), Memory AssessmentClinics Self-Rating Scale (MAC-S), Symbol Digit Coding (SDC), SDCDelayed Recall Task (DRT), Divided Attention Test (DAT), Visual SequenceComparison (VSC), DAT Dual Task (DAT Dual), Mini-Mental StateExamination (MMSE), and Geriatric Depression Scale (GDS), among others.

The term “cognitive function” refers to the special, normal, or properphysiologic activity of the brain, including, without limitation, atleast one of the following: mental stability, memory/recall abilities,problem solving abilities, reasoning abilities, thinking abilities,judging abilities, capacity for learning, perception, intuition,attention, and awareness. “Enhanced cognitive function” or “improvedcognitive function” refers to any improvement in the special, normal, orproper physiologic activity of the brain, including, without limitation,at least one of the following: mental stability, memory/recallabilities, problem solving abilities, reasoning abilities, thinkingabilities, judging abilities, capacity for learning, perception,intuition, attention, and awareness, as measured by any means suitablein the art. “Reduced cognitive function” or “impaired cognitivefunction” refers to any decline in the special, normal, or properphysiologic activity of the brain.

Administration can be on an as-needed or as-desired basis, for example,once-monthly, once-weekly, daily, or more than once daily. Similarly,administration can be every other day, week, or month, every third day,week, or month, every fourth day, week, or month, and the like.Administration can be multiple times per day. When utilized as asupplement to ordinary dietetic requirements, the composition may beadministered directly to the patient or otherwise contacted with oradmixed with daily feed or food.

Administration can also be carried out on a regular basis, for example,as part of a treatment regimen in the patient. A treatment regimen maycomprise causing the regular ingestion by the patient of an inventivecomposition in an amount effective to enhance cognitive function,memory, and behavior in the patient. Regular ingestion can be once aday, or two, three, four, or more times per day, on a daily or weeklybasis. Similarly, regular administration can be every other day or week,every third day or week, every fourth day or week, every fifth day orweek, or every sixth day or week, and in such a regimen, administrationcan be multiple times per day. The goal of regular administration is toprovide the patient with optimal dose of an inventive composition, asexemplified herein.

The compositions provided herein are, in one embodiment, intended for“long term” consumption, sometimes referred to herein as for ‘extended’periods. “Long term” administration as used herein generally refers toperiods in excess of one month. Periods of longer than two, three, orfour months comprise one embodiment of the instant invention. Alsoincluded are embodiments comprising more extended periods that includelonger than 5, 6, 7, 8, 9, or 10 months. Periods in excess of 11 monthsor 1 year are also included. Longer terms use extending over 1, 2, 3 ormore years are also contemplated herein. “Regular basis” as used hereinrefers to at least weekly, dosing with or consumption of thecompositions. More frequent dosing or consumption, such as twice orthrice weekly are included. Also included are regimens that comprise atleast once daily consumption. The skilled artisan will appreciate thatthe blood level of ketone bodies, or a specific ketone body, achievedmay be a valuable measure of dosing frequency. Any frequency, regardlessof whether expressly exemplified herein, that allows maintenance of ablood level of the measured compound within acceptable ranges can beconsidered useful herein. The skilled artisan will appreciate thatdosing frequency will be a function of the composition that is beingconsumed or administered, and some compositions may require more or lessfrequent administration to maintain a desired blood level of themeasured compound (e.g., a ketone body).

In one embodiment, the method comprises the use of MCT wherein R1, R2,and R3 are fatty acids containing a six-carbon backbone (tri-C6:0).Tri-C6:0 MCT are absorbed very rapidly by the gastrointestinal tract ina number of animal model systems. The high rate of absorption results inrapid perfusion of the liver, and a potent ketogenic response. Inanother embodiment, the method comprises the use of MCT wherein R1, R2,and R3 are fatty acids containing an eight-carbon backbone (tri-C8:0).In another embodiment, the method comprises the use of MCT wherein R1,R2, and R3 are fatty acids containing a ten-carbon backbone (tri-C10:0).In another embodiment, the method comprises the use of MCT wherein R1,R2, and R3 are a mixture of C8:0 and C 10:0 fatty acids. In anotherembodiment, the method comprises the use of MCT wherein R1, R2 and R3are a mixture of C6:0, C8:0, C10:0, and C12:0 fatty acids. In anotherembodiment, greater than 95% of R1, R2 and R3 carbon chains of the MCTare 8 carbons in length. In yet another embodiment, the R1, R2, and R3carbon chains are 6-carbon or 10-carbon chains. In another embodiment,50% of the R1, R2 and R3 carbon chains of the MCT are 8 carbons inlength and about 50% of the R1, R2 and R3 carbon chains of the MCT areabout 10 carbons in length. Additionally, utilization of MCT can beincreased by emulsification. Emulsification of lipids increases thesurface area for action by lipases, resulting in more rapid hydrolysisand release of MCFA. Methods for emulsification of these triglyceridesare well known to those skilled in the art.

In one embodiment, the method comprises the use of MCFA of 6, 8, 10 and12 carbon chain length or mixtures of the above.

Therapeutically effective amounts of the therapeutic agents can be anyamount or dose sufficient to bring about the desired effect and depend,in part, on the severity and stage of the condition, the size andcondition of the patient, as well as other factors readily known tothose skilled in the art. The dosages can be given as a single dose, oras several doses, for example, divided over the course of several weeks,as discussed elsewhere herein.

In one embodiment, the ketogenic compounds are administered orally. Inanother embodiment, the ketogenic compounds are administeredintravenously. Oral administration of MCT and other ketogenic compoundpreparations of intravenous MCT and other ketogenic compound solutionsare well known to those skilled in the art.

In one embodiment, oral and/or intravenous administration of acomposition comprising at least one compound capable of elevating ketonebody concentrations, such as, for example, MCT or MCFA, result inhyperketonemia. Hyperketonemia, in one embodiment, results in ketonebodies being utilized for energy in the brain even in the presence ofglucose. Additionally, hyperketonemia results in a substantial (39%)increase in cerebral blood flow (Hasselbalch, S. G., et al., Changes incerebral blood flow and carbohydrate metabolism during acutehyperketonemia, Am J Physiol, 1996, 270:E746-51). Hyperketonemia hasbeen reported to reduce cognitive dysfunction associated with systemichypoglycemia in normal humans (Veneman, T., et al., Effect ofhyperketonemia and hyperlacticacidemia on symptoms, cognitivedysfunction, and counterregulatory hormone responses during hypoglycemiain normal humans, Diabetes, 1994, 43:1311-7). Please note that systemichypoglycemia is distinct from the local defects in glucose metabolismthat occur in any disease- or age-associated cognitive decline, such asAD, AAMI, and the like.

In all embodiments, the invention provides the subject compositionscomprising at least one compound that is capable of elevating ketonebody concentrations. Such compounds are also collectively referred to asketone body precursor compounds or ketogenic compounds. Such compoundsinclude compounds such as, for example, MCT, MCFA, and prodrugs,metabolic precursors, and so on, of ketone bodies. For example, in oneembodiment, the compound capable of elevating ketone body concentrationsin the body include one or more prodrugs, which can be metabolicallyconverted to the subject compounds by the recipient host. As usedherein, a prodrug is a compound that exhibits pharmacological activityafter undergoing a chemical transformation in the body. A prodrug canalso be referred to as a metabolic precursor if the conversion of theprodrug directly results in the formation of a ketone body. MCT and MCFAmust be first oxidized to acetyl-CoA, then undergo several steps beforebeing synthesized into ketone bodies. The class of ketone body precursorcompounds include, the compounds described hereinbelow. The ketone bodyprecursor compounds, in one embodiment, are administered in a dosagerequired to increase blood ketone bodies to a level required to treatand/or prevent the occurrence of any disease- or age-associatedcognitive decline, such as AD, AAMI, and the like. Appropriate dosagesof all of these compounds can be determined by one of skill in the art.

A wide variety of prodrug formulations are known in the art. Forexample, prodrug bonds may be hydrolyzable, such as esters oranhydrides, or enzymatically biodegradable, such as amides.

Ketone body precursor compounds e.g., compounds capable of elevatingketone body concentrations, appropriate for use with the presentinvention includes any compounds that are capable of directly elevatingketone body concentrations in the body of a mammal, e.g., a patient, andmay be determined by one of skill in the art. These compounds can mimicthe effect of increasing oxidation of fatty acids and include but arenot limited to the ketone bodies, D-beta-hydroxybutyrate andacetoacetate, and metabolic precursors of these. The term metabolicprecursor, used in this embodiment, can refer to compounds that comprise1,3 butane diol, acetoacetyl or D-beta-hydroxybutyrate moieties such asacetoacetyl-1-1,3-butane diol, acetoacetyl-D-beta-hydroxybutyrate, andacetoacetylglycerol. Esters of any such compound with monohydric,dihydric or trihydric alcohols are also included in yet anotherembodiment. Metabolic precursors also include polyesters ofD-beta-hydroxybutyrate, and acetoacetate esters ofD-beta-hydroxybutyrate. Polyesters of D-beta-hydroxybutyrate includeoligomers of this polymer designed to be readily digestible and/ormetabolized by humans or mammals. These preferably are of 2 to 100repeats long, typically 2 to 20 repeats long, and most conveniently from3 to 10 repeats long. Examples of poly D-beta-hydroxybutyrate orterminally oxidized poly-D-beta-hydroxybutyrate esters useable as ketonebody precursors are given below:

In each case, n is selected such that the polymer or oligomer is readilymetabolized on administration to a human or mammal body to provideelevated ketone body levels in blood. Values of n are integers of 0 to1,000, more preferably 0 to 200, still more preferably 1 to 50, mostpreferably 1 to 20, particularly conveniently being from 3 to 5. In eachcase m is an integer of 1 or more, a complex thereof with one or morecations or a salt thereof for use in therapy or nutrition. Examples ofcations and typical physiological salts are described herein, andadditionally include sodium, potassium, magnesium, calcium, eachbalanced by a physiological counter-ion forming a salt complex,L-lysine, L-arginine, methyl glucamine, and others known to thoseskilled in the art.

Also included in the definition of a ketone body precursor compound areseveral other ketone body precursor compounds useful for treatingreduced neuronal metabolism; including esters of polyhydric alcohols,3-hydroxyacid esters and glycerol esters, as described more fullyhereinbelow. As used herein, “derivative” refers to a compound orportion of a compound that is derived from or is theoretically derivablefrom a parent compound; The term “hydroxyl group” is represented by theformula —OH; the term “alkoxy group” is represented by the formula —OR,where R can be an alkyl group, including a lower alkyl group, optionallysubstituted with an alkenyl, alkynyl, aryl, aralkyl, cycloalkyl,halogenated alkyl, or heterocycloalkyl group, as defined below; the term“ester” is represented by the formula —OC(O)R, where R can be an alkyl,alkenyl, alkynyl, aryl, aralkyl, cycloalkyl, halogenated alkyl, orheterocycloalkyl group, as defined below; the term “alkyl group” isdefined as a branched or unbranched saturated hydrocarbon group of 1 to24 carbon atoms, such as methyl, ethyl, n-propyl, isopropyl, n-butyl,isobutyl, t-butyl, pentyl, hexyl, heptyl, octyl, decyl, tetradecyl,hexadecyl, eicosyl, tetracosyl and the like. A “lower alkyl” group is asaturated branched or unbranched hydrocarbon having from 1 to 10 carbonatoms; the term “alkenyl group” is defined as a hydrocarbon group of 2to 24 carbon atoms and structural formula containing at least onecarbon-carbon double bond; the term “alkynyl group” is defined as ahydrocarbon group of 2 to 24 carbon atoms and a structural formulacontaining at least one carbon-carbon triple bond; the term “halogenatedalkyl group” is defined as an alkyl group as defined above with one ormore hydrogen atoms present on these groups substituted with a halogen(F, Cl, Br, I); the term “cycloalkyl group” is defined as a non-aromaticcarbon-based ring composed of at least three carbon atoms. Examples ofcycloalkyl groups include, but are not limited to, cyclopropyl,cyclobutyl, cyclopentyl, cyclohexyl, etc. The term “heterocycloalkylgroup” is a cycloalkyl group as defined above where at least one of thecarbon atoms of the ring is substituted with a heteroatom such as, butnot limited to, nitrogen, oxygen, sulfur, or phosphorous; the term“aliphatic group” is defined as including alkyl, alkenyl, alkynyl,halogenated alkyl and cycloalkyl groups as defined above. A “loweraliphatic group” is an aliphatic group that contains from 1 to 10 carbonatoms; the term “aryl group” is defined as any carbon-based aromaticgroup including, but not limited to, benzene, naphthalene, etc. The term“aromatic” also includes “heteroaryl group,” which is defined as anaromatic group that has at least one heteroatom incorporated within thering of the aromatic group. Examples of heteroatoms include, but are notlimited to, nitrogen, oxygen, sulfur, and phosphorous. The aryl groupcan be substituted with one or more groups including, but not limitedto, alkyl, alkynyl, alkenyl, aryl, halide, nitro, amino, ester, ketone,aldehyde, hydroxy, carboxylic acid, or alkoxy, or the aryl group can beunsubstituted; the term “aralkyl” is defined as an aryl group having analkyl group, as defined above, attached to the aryl group. An example ofan aralkyl group is a benzyl group; “esterification” refers to thereaction of an alcohol with a carboxylic acid or a carboxylic acidderivative to give an ester; “transesterification” refers to thereaction of an ester with an alcohol to form a new ester compound. Theterm “3-hydroxybutyrate” is used interchangeably with the term“3-hydroxybutyric acid.”

In one embodiment, a compound capable of elevating ketone bodyconcentrations includes compounds according to formula:

wherein R is a polyhydric alcohol residue; n, m and x representintegers; and m is less than or equal to x.

Physiologically compatible alcohols suitable for forming esters with(R)-3-hydroxybutyrate and derivatives thereof include monohydric andpolyhydric alcohols. Esters of polyhydric alcohols deliver a higherdensity of (R)-3-hydroxybutyrate equivalents per equivalent of(R)-3-hydroxybutyrate derivative using shorter (R)-3-hydroxybutyrateoligomers. Shorter oligomers generally are more readily hydrolyzed togive elevated concentrations of (R)-3-hydroxybutyrate in blood. Examplesof polyhydric alcohols suitable for preparing such esters includecarbohydrates and carbohydrate derivatives, such as carbohydratealcohols, examples of carbohydrates include, without limitation,altrose, arabinose, dextrose, erythrose, fructose, galactose, glucose,gulose, idose, lactose, lyxose, mannose, ribose, sucrose, talose,threose, xylose and the like. Additional examples of carbohydratesuseful for preparing (R)-3-hydroxybutyrate derivatives include aminoderivatives, such as galactosamine, glucosamine and mannosamine,including N-acetyl derivatives, such as N-acetylglucosamine and thelike. Examples of carbohydrates also include carbohydrate derivatives,such as alkyl glycosides. Examples of carbohydrate alcohols include,without limitation, glycerol, mannitol, ribitol, sorbitol, threitol,xylitol and the like. The enantiomers of the above-listed carbohydratesand carbohydrate alcohols also can be used to prepare(R)-3-hydroxybutyrate derivatives according to the above formula.

Embodiments include compounds where n is from 1 to about 100; wherein xis from 1 to about 20; wherein m is from 1 to about 20. One embodimentincludes a compound wherein R is (R)-1,3-butanediol.

In another embodiment, compounds capable of elevating ketone bodyconcentrations include compounds of the formula

where n and m independently are integers from 1 to about 100. In someembodiments, n and m are the same; n and m are different; and wherein nand m are 3.

In addition, compounds capable of elevating ketone body concentrationsinclude ester compounds of R-3-hydroxybutyrate according to the formula

wherein n is an integer from 1 to about 100. In one embodiment, n is 3.

Other compounds capable of elevating ketone body levels include3-hydroxyacids. The compositions include 3-hydroxyacids, linear orcyclic oligomers thereof, esters of the 3-hydroxyacids or oligomers,derivatives of 3-hydroxyacids, and combinations thereof. In oneembodiment, the compositions include the cyclic macrolide ofR-3-hydroxyacids containing 3, 4, or 5 monomeric subunits.3-hydroxyacids include 3-hydroxybutyric acid, 3-hydroxyvaleric acid,3-hydroxyhexanoic acid and 3-hydroxyheptanoic acid. In some embodiments,the length of the oligomer must be such that the derivative has asuitable digestion rate for sustained release of monomer. In anotherembodiment, the cyclic trimer (triolide) is used in a combination withother cyclic oligolides or linear esters and/or mixtures of both.

The general formula for 3-hydroxyacids is:

wherein R₁ is selected from hydrogen, methyl, alkyl, alkenyl, aryl,arylalkyl, heteroalkyl, heteroaryl, thiol, disulfide, ether, thiolether,amine, amide, halogen. R₂ and R₃ are independently selected fromhydrogen, methyl, alkyl, alkenyl, aryl, arylalkyl, heteroalkyl,heteroaryl, thiol, disulfide, ether, thiolether, amine, amide, halogen,hydroxy, ester, nitrogen-substituted radicals, and/or oxygen-substitutedradicals. R₄ is selected from hydrogen, alkyl, alkenyl, aryl, arylalkyl,heteroalkyl, heteroaryl, thiol, disulfide, ether, thiolether, amine,amide, halogen, hydroxy, ester, nitrogen-substituted radicals, and/oroxygen-substituted radicals. Further, when R₄ is not hydrogen or ahalogen, R₃ can be a direct bond to R₄ and R₄ can be methyl.

Other compounds capable of elevating ketone body levels include glycerolesters, namely, not readily water-soluble glycerides of at least oneketo or hydroxy acid, having the formula

wherein two or three of the groups R₁, R₂ and R₃ independently of eachother, are one or more of the groups acetoacetate, alpha-ketopropionate,beta-hydroxybutyrate and alpha-hydroxypropionate, and when only two ofthe groups R₁, R₂ and R₃ are any of said groups, the third of them is ahydroxy group or a residue of a saturated or unsaturated fatty acidcontaining 2 to 24 carbon atoms. Other glycerol esters are envisioned,particularly not readily water-soluble glycerides of at least one ketoor hydroxy acid, having the formula

wherein one R group is hydrogen, and two R groups are (—COCH₂, COCH₃).Additionally, wherein each R is the same or different and is hydrogen,or (—COCH₂, COCH₃), provided that at least one R is not hydrogen andwherein R′ is a linear acid ester of even carbon number from 2 to 20carbons.

This invention also provides the inventive compositions in oneembodiment in administratively convenient formulations including dosageunits incorporated into a variety of containers. Dosages of theinventive compositions, such as, for example, those comprising MCT, maybe administered in an effective in an effective amount to increase thecognitive ability of patients afflicted with diseases of reducedneuronal metabolism, such as in patients with any disease- orage-associated cognitive decline, such as, AD, AAMI, and the like.

In one embodiment, the inventive compositions result in elevating ketoneconcentrations in the body, and in this embodiment, the compositions areadministered in an amount that is effective to induce hyperketonemia. Inone embodiment, hyperketonemia results in ketone bodies being utilizedfor energy in the brain.

In one embodiment, the composition increases the circulatingconcentration of at least one type of ketone body in the mammal orpatient. In one embodiment, the circulating ketone body isD-beta-hydroxybutyrate. The amount of circulating ketone body can bemeasured at a number of times post administration, and in oneembodiment, is measured at a time predicted to be near the peakconcentration in the blood, but can also be measured before or after thepredicted peak blood concentration level. Measured amounts at theseoff-peak times are then optionally adjusted to reflect the predictedlevel at the predicted peak time. In one embodiment, the predicted peaktime is at about two hours. Peak circulating blood level and timing canvary depending on factors known to those of skill in the art, includingindividual digestive rates, co-ingestion or pre- or post-ingestion offoods, drinks, etc., as known to one of skill in the art. In oneembodiment, the peak blood level reached of D-beta-hydroxybutyrate isbetween about 0.05 millimolar (mM) to about 50 mM. Another way todetermine whether blood levels of D-beta-hydroxybutyrate are raised toabout 0.05 to about 50 mM is by measurement of D-beta-hydroxybutyrateurinary excretion a range in the range of about 5 mg/dL to about 160mg/dL. In other embodiments, the peak blood level is raised to about 0.1to about 50 mM, from about 0.1 to about 20 mM, from about 0.1 to about10 mM, to about 0.1 to about 5 mM, more preferably raised to about 0.15to about 2 mM, from about 0.15 to about 0.3 mM, and from about 0.2 toabout 5 mM, although variations will necessarily occur depending on theformulation and host, for example, as discussed above. In otherembodiments, the peak blood level reached of D-beta-hydroxybutyrate willbe at least about 0.05 mM, at least about 0.1 mM, at least about 0.15mM, at least about 0.2 mM, at least about 0.5 mM, at least about 1 mM,at least about 1.5 mM, at least about 2 mM, at least about 2.5 mM, atleast about 3 mM, at least about 4 mM, at least about 5 mM, at leastabout 10 mM, at least about 15 mM, at least about 20 mM, at least about30 mM, at least about 40 mM, and at least about 50 mM.

Effective amount of dosages of compounds for the inventive compositions,i.e., compounds capable of elevating ketone body concentrations in anamount effective for the treatment of or prevention of loss of cognitivefunction caused by reduced neuronal metabolism will be apparent to thoseskilled in the art. As discussed herein above, such effective amountscan be determined in light of disclosed blood ketone levels. Where thecompound capable of elevating ketone body concentrations is MCT, the MCTdose, in one embodiment, is in the range of about 0.05 g/kg/day to about10 g/kg/day of MCT. In other embodiments, the dose will be in the rangeof about 0.25 g/kg/day to about 5 g/kg/day of MCT. In other embodiments,the dose will be in the range of about 0.5 g/kg/day to about 2 g/kg/dayof MCT. In other embodiments, the dose will be in the range of about 0.1g/kg/day to about 2 g/kg/day. In other embodiments, the dose of MCT isat least about 0.05 g/kg/day, at least about 0.1 g/kg/day, at leastabout 0.15 g/kg/day, at least about 0.2 g/kg/day, at least about 0.5g/kg/day, at least about 1 g/kg/day, at least about 1.5 g/kg/day, atleast about 2 g/kg/day, at least about 2.5 g/kg/day, at least about 3g/kg/day, at least about 4 g/kg/day, at least about 5 g/kg/day, at leastabout 10 g/kg/day, at least about 15 g/kg/day, at least about 20g/kg/day, at least about 30 g/kg/day, at least about 40 g/kg/day, and atleast about 50 g/kg/day.

Convenient unit dosage containers and/or formulations include tablets,capsules, lozenges, troches, hard candies, nutritional bars, nutritionaldrinks, metered sprays, creams, and suppositories, among others. Thecompositions may be combined with a pharmaceutically acceptableexcipient such as gelatin, oil(s), and/or other pharmaceutically activeagent(s). For example, the compositions may be advantageously combinedand/or used in combination with other therapeutic or prophylacticagents, different from the subject compounds. In many instances,administration in conjunction with the subject compositions enhances theefficacy of such agents. For example, the compounds may beadvantageously used in conjunction with antioxidants, compounds thatenhance the efficiency of glucose utilization, and mixtures thereof.

In one embodiment, the subject is intravenously infused with ketogeniccompounds such as MCT, MCFA, directly, to a level required to treat andprevent the occurrence of diseases of reduced neuronal metabolism.Preparation of intravenous lipids and ketone body solutions are wellknown to those skilled in the art.

In one embodiment, the invention provides a formulation comprising amixture of MCT and carnitine to provide elevated blood ketone levels.The nature of such formulations will depend on the duration and route ofadministration. Such formulations can be in the range of 0.05 g/kg/dayto 10 g/kg/day of MCT and 0.05 mg/kg/day to 10 mg/kg/day of carnitine orits derivatives. In one embodiment, an MCT dose can be in the range of0.05 g/kg/day to 10 g/kg/day of MCT. The dose can be in the range of0.25 g/kg/day to 5 g/kg/day of MCT. The dose can also be in the range of0.5 g/kg/day to 2 g/kg/day of MCT. In some embodiments, a carnitine orcarnitine derivative dose can be in the range of 0.05 mg/kg/day to 10mg/kg/day. The carnitine or carnitine derivative dose can be in therange of 0.1 mg/kg/day to 5 mg/kg/day. The carnitine or carnitinederivative dose can also be in the range of 0.5 mg/kg/day to 1mg/kg/day. Variations will necessarily occur depending on theformulation and/or host, for example.

In one embodiment, a formulation comprises a range of about 1 to about500 g of emulsified MCT combined with about 1 to about 2000 mg ofcarnitine. Amounts of MCT can be at least about 1 g, at least about 10g, at least about 50 g, at least about 100 g, at least about 150 g, atleast about 200 g, at least about 250 g, at least about 300 g, at leastabout 400 g. Amounts of carnitine can be at least about 1 g, at leastabout 50 g, at least about 100 g, at least about 250 g, at least about500 g, at least about 1000 g, at least about 1250 g, at least about 1500g. Another formulation comprises 50 g MCT (95% triC8:0) emulsified with50 g of mono- and di-glycerides combined with 500 mg of L-carnitine.Such a formulation is well tolerated and generally induceshyperketonemia for 3-4 hours in human subjects.

The daily dose of MCT can be also be measured in terms of grams of MCTper kg of body weight (BW) of the mammal. The daily dose of MCT canrange from about 0.01 g/kg to about 10.0 g/kg BW of the mammal.Preferably, the daily dose of MCT is from about 0.1 g/kg to about 5 g/kgBW of the mammal. More preferably, the daily dose of MCT is from about0.2 g/kg to about 3 g/kg of the mammal. Still more preferably, the dailydose of MCT is from about 0.5 g/kg to about 2 g/kg of the mammal.

In some embodiments, the inventive compounds may be co administered withcarbohydrate, or be co-formulated with carbohydrate. Carbohydrate caninclude more than one type of carbohydrate. Appropriate carbohydratesare known in the art, and include simple sugars, such as glucose,fructose, sucrose, and the like, from conventional sources such as cornsyrup, sugar beet, and the like. If co-formulated, the amount ofcarbohydrate to use can include at least about 0.1 g, at least about 1g, at least about 10 g, at least about 50 g, at least about 100 g, atleast about 150 g, at least about 200 g, at least about 250 g, at leastabout 300 g, at least about 400 g. Amounts of carnitine can be at leastabout 1 g, at least about 50 g, at least about 100 g. The compositionscan comprise from about 15% to about 40% carbohydrate, on a dry weightbasis. Sources of such carbohydrates include grains or cereals such asrice, corn, sorghum, alfalfa, barley, soybeans, canola, oats, wheat, ormixtures thereof. The compositions also optionally comprise othercomponents that comprise carbohydrates such as dried whey and otherdairy products or by-products.

In another embodiment, the methods of the present invention furthercomprise determination of the patients' genotype or particular alleles.In one embodiment, the patient's alleles of the apolipoprotein E geneare determined. It has been found that non-E4 carriers performed betterthan those with the E4 allele when elevated ketone body levels wereinduced with MCT. Also, those with the E4 allele had higher fastingketone body levels and the levels continued to rise at the two hour timeinterval. Therefore, E4 carriers may require higher ketone levels oragents that increase the ability to use the ketone bodies that arepresent.

In another embodiment, the compositions comprising compounds capable ofincreasing ketone body concentrations are food products formulatedspecifically for human consumption. These will include foods andnutrients intended to supply necessary dietary requirements of a humanbeing as well as other human dietary supplements. In a one embodiment,the food products formulated for human consumption are complete andnutritionally balanced while in others they are intended as nutritionalsupplements to be used in connection with a well-balanced or formulateddiet.

In another embodiment, the composition is a food supplement, such asdrinking water, beverage, liquid concentrate, gel, yogurt, powder,granule, paste, suspension, chew, morsel, treat, snack, pellet, pill,capsule, tablet, or any other delivery form. The nutritional supplementscan be specially formulated for consumption by a particular species oreven an individual mammal, such as companion mammal, or a human. In oneembodiment, the nutritional supplement can comprise a relativelyconcentrated dose of MCT such that the supplement can be administered tothe mammal in small amounts, or can be diluted before administration toa mammal. In some embodiments, the nutritional supplement or otherMCT-containing composition may require admixing with water or the likeprior to administration to the mammal, for example to adjust the dose,to make it more palatable, or to allow for more frequent administrationin smaller doses.

Sources of the MCT include any suitable source, semi-synthetic,synthetic or natural. Examples of natural sources of MCT include plantsources such as coconuts and coconut oil, palm kernels and palm kerneloils, and animal sources such as milk from any of a variety of species,e.g., goats.

EXAMPLES

The following examples are provided for illustrative purposes only andare not intended to limit the scope of the invention.

Example 1 Pharmacogenomics in a Ketone Body Based Treatment ofAlzheimer's Disease

One promising treatment for Alzheimer's disease is the induction ofketosis. Study KET-04-001 examined the pharmacogenomic effects ofseveral genetic markers in a group of mild to moderate AD patientstreated with a ketogenic agent. The test compound was AC-1202. AC-1202is a formulation of medium chain triglycerides (MCT) designed to safelyelevate serum ketone bodies even in the presence of carbohydrate in thediet. MCT were chosen for this study due to their excellent safetyprofile and long historical use in lipid malabsorption disorders andketogenic diets. Due to the unique physical properties of AC-1202, it ismetabolized differently from the more common long chain triglycerides(LCT). If sufficiently large amounts of AC-1202 are consumed a mildstate of ketosis can be induced.

Subjects

Two hundred fifty-three participants with a diagnosis of probable ADwere screened. The study recruited outpatients with a diagnosis ofprobable AD of mild to moderate severity according to NINCDS-ADRDA andDSM IV criteria, with a MMSE score of between 14 and 24 (inclusive) atScreen. A CT or MRI within 24 months prior to Screen had to show nosigns of tumor, structural abnormality, or degenerative disease.Subjects were required to have a Modified Hachinski Ischemia Scale score54. Subjects and their caregivers provided informed consent, whichincluded an optional provision for genotyping. At their discretion,participants could consent to be tested for APOE, and/or additional DNAmarkers. Genetic information was not shared with site personnel or studyparticipants.

Key exclusion criteria at Screen included: major depression asdetermined by a Cornell Scale for Depression in Dementia score ofclinically significant hypothyroidism as determined by thyroid functionassessment, clinically significant B12 deficiency within 12 months priorto Baseline, clinically significant renal disease or insufficiency,clinically significant hepatic disease or insufficiency, and any type ofdiabetes.

Subjects receiving currently approved AD medications were eligible forenrollment in the study provided that they had been maintained on stabledosing for at least 3 months prior to Screen and were required to remainon stable dosing throughout the duration of the study.

Study Design

Subjects were randomized in a 1:1 ratio to receive either AC-1202 ormatching Placebo for 90 days. A permutated block randomization code witha block size of 4 was used. Subjects were issued study kits labeled witha unique site and subject number. The participants, those administeringthe interventions, and those assessing the outcomes were blinded togroup assignment. Subjects who prematurely discontinued the study werereplaced and assigned to investigational product by an independentun-blinded medical monitor in such a manner as to obtain approximately50 subjects within each treatment group.

Investigational product was formulated as an emulsified spray driedpowder consisting of 33% AC-1202 (NeoBee 895, Stepan Chemical Company),64% gum Acacia (Instagum, CNI) and 2.6% syloid (244FP, Grace Davison).Placebo was isocaloric to the active formulation and consisted of amixture of 51% gum acacia, 37% dextrose, 10% safflower oil and 2% syloid(prepared by The Chemins Company). Investigational product was given asa powder packaged in 30 gram sachets containing either active(equivalent to 10 grams of AC-1202) or matching Placebo.

The contents of the sachets were to be mixed in one 8 oz. glass of aliquid such as water, milk, or juice prior to consumption. Theseinstructions were later amended to recommend reconstitution with a mealreplacement drink, Ensure (Abbott Laboratories), to improve producttolerability. For the first seven days of the study, subjects receivedone 30 gm sachet daily. On Day 8, each subject was asked to increase thedose to two 30 gm sachets daily, and continue on that dose through Day90. Daily doses were administered during breakfast, except on clinicvisit days when the participants were asked to eat breakfast prior totheir scheduled visit.

Safety evaluations included physical examinations, vital signmeasurements, routine serum chemistry and hematology tests, andelectrocardiograms performed at Screen and Day 104. Treatment emergentadverse events and any changes in concomitant medication administrationwere recorded at all clinic visits.

Assays β-hydroxybutyrate Concentration Levels

Pre- and post-dosing serum samples were collected and analyzed by AlliedResearch International (formerly SFBC) of Miami, Fla. using the BHBLiquicolor® diagnostic kit supplied by Stanbio Laboratories (Boenre,Tex.). The normal range (12-hour fasting) is 0.02 mM to 0.27 mM.

Statistical Analysis

An intention-to-treat (ITT) analysis was used as the primary analysis ofefficacy, where all subjects who were randomized, received studymedication, and who completed at least one follow-up visit wereincluded. All missing efficacy data were imputed using the lastobservation carried forward (LOCF) method. The primary end pointsestablished a priori were change from baseline in ADAS-Cog and theADCS-CGIC global scores at Day 90. Secondary outcome measures includedthe MMSE, and interactions associated with APOE genotype and BHBconcentration levels.

An overall two-way ANCOVA was used to evaluate the treatment effect,along with genotype effects and treatment by genotype interactions forCmax serum BHB levels at Day 90. The ANCOVA model included independentfactors for treatment, genotype, and treatment by genotype interactions.A variable for baseline serum BHB level was included as a covariate.Correlations between the Cmax serum BHB level on Day 90 and the changefrom baseline total score was determined by Pearson correlationstatistics.

Genotyping

Several genetic markers were chosen for their ability to influence theeffectiveness of a ketone body based therapy in Alzheimer's disease inStudy KET-04-001. Participants in Study KET-04-001 who consented toadditional genetic analysis were genotyped by polymerase chain reactionsequencing for 15 single nucleotide polymorphisms (SNPs) in the genesIDE, LDLR, APOE, PON1, IGFR1 and IL1B (described in more detail below).Genotyping was accomplished as follows: genomic DNA was extracted fromEDTA anti-coagulated venous blood with use of the QIA-amp Blood-DNAmini-reagent set (Qiagen) according to the manufacturer's instructions.DNA was eluted in 200 μL of water in the final step and stored at −20°C. until required. Individual primer sets as described elsewhere hereinwere used to amplify regions containing the polymorphism of interest.DNA was amplified in 5× buffer [300 mMTris-HCl, pH 9.0, 62.5 mM(NH₄)₂SO₄], 2 mM MgCl₂, four dNTPs (dATP, dCTP, dGTP, and dTTP; 250 uMeach), 1 U of AmpliTaq DNA polymerase, and 8 pmol each of primers in afinal volume of 20 uL. Samples were denatured at 95° C. for 3 min,annealed at 47° C. for 60 s, and elongated at 72° C. for 60 s. This wasfollowed by 35 cycles of denaturation (15 s at 95° C.), annealing (30 sat 47° C.), and extension (20 s at 72° C.). The final cycle was followedby 10 min at 72° C. and 1 min at 25° C. Genotyping was ascertainedthrough direct sequencing of PCR products using the ABI PRISM BigDyeTerminator Cycle Sequencing Ready Reaction Kit and analyzed on an ABIPRISM 377 DNA Sequencer (Applied Biosystems, Foster City, Calif., USA).

The presence of IDE_(—)7 or IDE rs2251101 was determined by PCRamplification and sequencing a region of genomic DNA isolated from eachpatient (a relevant portion of this gene is shown in SEQ ID NO:3). Theregion amplified contained the polymorphism. PCR was done using standardmolecular biology techniques. Primers SEQ ID NO:1 (CAGCACTTTAGGAGGCCAAG)and SEQ ID NO:2 (CTGCCCTTACAGGGATGAAA) were used to generate a 682 bpfragment. This fragment was purified and then sequenced usingfluorescent sequencing techniques to determined genotype for eachpatient.

The presence of homozygosity for A for rs2229765 in of insulin-likegrowth factor 1 receptor precursor (IGFR-1) (a relevant portion of thisgene is shown in SEQ ID NO:6) was determined by PCR amplification andsequencing a region of genomic DNA isolated from each patient. Theregion amplified contained the polymorphism. PCR was done using standardmolecular biology techniques. Primers SEQ ID NO:4 (GGCTTAGAGTTCCCCCAAAG)and SEQ ID NO:5 (CTTGCTGATGCCTGTGTTGT) were used to generate a 529 bpfragment. This fragment was purified and then sequenced usingfluorescent sequencing techniques to determined genotype for eachpatient.

The presence of homozygosity for T at IL1B rs1143627 (a relevant portionof this gene is shown in SEQ ID NO:9) as well as the presence ofhomozygosity for C at IL1B rs16944 (a relevant portion of this gene isshown in SEQ ID NO:10) was detected by PCR amplification and sequencinga region of genomic DNA isolated from each patient. The region amplifiedcontained the polymorphism. PCR was done using standard molecularbiology techniques. Primers SEQ ID NO:7 (CACAAAGAGGCAGAGAGACAGA) and SEQID NO:8 (GTCTTGCAGGGTTGTGTGAG) were used to generate a 799 bp fragment.This fragment was purified and then sequenced using fluorescentsequencing techniques to determined genotype for each patient.

Genotype LDLR rs2738447 was determined by PCR amplification andsequencing a region of genomic DNA isolated from each patient. Theregion amplified contained the polymorphism. PCR was done using standardmolecular biology techniques. Primers SEQ ID NO:13 and SEQ ID NO:14 wereused to generate a 590 bp fragment. This fragment was purified and thensequenced using fluorescent sequencing techniques to determined genotypefor each patient.

Genotype LDLR rs7259278 was determined by PCR amplification andsequencing a region of genomic DNA isolated from each patient. Theregion amplified contained the polymorphism. PCR was done using standardmolecular biology techniques. Primers SEQ ID NO:13 and SEQ ID NO:14 wereused to generate a 590 bp fragment. This fragment was purified and thensequenced using fluorescent sequencing techniques to determined genotypefor each patient.

Genotype LDLR rs11669576 was determined by PCR amplification andsequencing a region of genomic DNA isolated from each patient. Theregion amplified contained the polymorphism. PCR was done using standardmolecular biology techniques. Primers SEQ ID NO:11(CACCTGGCTGTTTCCTTGAT) and SEQ ID NO:12 (TTCCTGTTCCACCAGTAGGG) were usedto generate a 530bp fragment. This fragment was purified and thensequenced using fluorescent sequencing techniques to determined genotypefor each patient.

The genotype for LDLR rs1799898 was determined by PCR amplification andsequencing a region of genomic DNA isolated from each patient (arelevant portion of this gene is shown in SEQ ID NO:15). The regionamplified contained the polymorphism. PCR was done using standardmolecular biology techniques. Primers SEQ ID NO: 13 (GTCACAGGGGAGGGGTTC)and SEQ ID NO:14 (CTACTGGGGAGCCTGAGACA) were used to generate a 590 bpfragment. This fragment was purified and then sequenced usingfluorescent sequencing techniques to determined genotype for eachpatient.

The genotype for heterozygosity for Butyrylcholine esterase (BCHE) Kvariant rs1803274 (a relevant portion of this gene is shown in SEQ IDNO:18) was determined by PCR amplification and sequencing a region ofgenomic DNA isolated from each patient. The region amplified containedthe polymorphism. PCR was done using standard molecular biologytechniques. Forward primer was SEQ ID NO: 16(CAGTTAATGAAACAGATAAAAATTTT) and reverse primer was SEQ ID NO:17(CAATATTATCCTTCTGGATT).

Genotypes Apolipoprotein E (APOE) promoter variant rs405509 isdetermined by PCR amplification and sequencing a region of genomic DNAisolated from each patient (a relevant portion of this gene is shown inSEQ ID NO:21). The region amplified contained the polymorphism. PCR wasdone using standard molecular biology techniques. Primers SEQ ID NO:19(GCCTAGCCCCACTTTCTTTT) and SEQ ID NO:20 (AGGTGGGGCATAGAGGTCTT) were usedto generate a 587 bp fragment. This fragment was purified and thensequenced using fluorescent sequencing techniques to determined genotypefor each patient.

Detection of genotype for Serum paraoxonase/arylesterase 1 (PON1) rs662:determined by PCR amplification and sequencing a region of genomic DNAisolated from each patient. The region amplified contained thepolymorphism. PCR was done using standard molecular biology techniques.Primers SEQ ID NO:22 (AAGGCTCCATCCCACATCTT) and SEQ ID NO:23(TCATCACAGTTCCCCCTCTT) were used to generate a 574 bp fragment. Thisfragment was purified and then sequenced using fluorescent sequencingtechniques to determined genotype for each patient.

For snps the IUPAC-IUB/GCG Ambiguity Codes were used. The table belowgives: 1. the ambiguity codes used in DNA sequences 2. which of the fourbases (A,C,T,G) are represented by the codes 3. the complement of theambiguity code

IUPAC-IUB/GCG Code Meaning Complement A A T C C G G G C T/U T A M A or CK R A or G Y W A or T W S C or G S Y C or T R K G or T M V A or C or G BH A or C or T D D A or G or T H B C or G or T V X/N G or A or T or C X .not G or A or T or C .

Frequency of Genotypes

Frequency and number of each genotype are shown in Table 1. Note, crefers to an individual who is a c/c homozygote, het refers to aheterozygote for that SNP. Note in some cases an unambiguous genotypecould not be assigned and these are represented with a “?” symbol.

TABLE 1 Frequency and counts of genotypes Gene SNP Genotype CountFrequency IL1B rs1143627 C 15 0.11719 Het 53 0.41406 T 60 0.46875 Total128 1 IL1B rs16944 C 60 0.46875 Het 53 0.41406 T 15 0.11719 Total 128 1IGF1R rs2229765 A 19 0.14074 G 49 0.36296 Het 67 0.4963 Total 135 1IGF1R rs28401726 C 109 0.80741 G 2 0.01481 Het 23 0.17037 het? 1 0.00741Total 135 1 PON1 rs662 a 61 0.45185 g 15 0.11111 het 59 0.43704 Total135 1 LDLR 13 rs7259278 g 101 0.77692 het 25 0.19231 t 4 0.03077 Total130 1 LDLR 13 rs2738447 a 24 0.18462 c 44 0.33846 het 62 0.47692 Total130 1 LDLR 13 rs1799898 c 87 0.66923 het 34 0.26154 het? 7 0.05385 t 20.01538 Total 130 1 LDLR 13 rs688 c 46 0.34848 het 62 0.4697 t 240.18182 Total 132 1 LDLR 13 snp 5 c 127 0.96212 het 5 0.03788 Total 1321 IDE rs2251101 c 16 0.11765 het 53 0.38971 t 67 0.49265 Total 136 1LDLR 8 rs11669576 g 123 0.90441 het 13 0.09559 Total 136 1 BUCHErs1803274 a 3 0.02239 g 85 0.63433 het 46 0.34328 Total 134 1 APOErs449647 a 88 0.70968 e? 1 0.00806 het 29 0.23387 t 6 0.04839 Total 1241 APOE rs405509 g 21 0.16935 het 56 0.45161 t 47 0.37903 Total 124 1APOE −427 het 13 0.10484 t 111 0.89516 Total 124 1

Genotype Frequency

The frequency of each polymorphism was examined relative to datapublished in the HapMap project (www.hapmap.org). In some cases HapMapdata was not available and other databases were used, such as the DECODEdatabase. The HapMap database is based on a relatively small sampling ofhumans from different geographical locations around the globe. There arefour main groups of people. The first group is individuals from theYoruba people of Ibidan Peninsula in Nigeria (referred to as YRI). Thesecond group is from the CEPH project in Utah, exclusively Americans ofEuropean ancestry (referred to as CEU). The third group is composed ofindividuals from the Han Chinese population of Beijing (referred to asCHB). The fourth group is composed of unrelated individuals of Japaneseancestry from the Tokyo area (referred to as JPT).

In most cases frequencies found in the KET-04-001 study agreed withpublished frequencies from a European American population from Utah. Instudy KET-04-001, 94.5% of subjects reported themselves asCaucasian/white, 4.8% Hispanic and 0.7% Black.

In some cases the frequencies differed. For example, the frequency ofthe IDE rs2251101 C/C genotype was quite low in the HapMap database(0.0314) and considerably higher in the KET-01-004 study (0.117). Thehigher frequency of the c/c genotype in the KET-04-001 study is probablya due to Accera's study utilizing an AD population. The C/C genotype hasbeen identified in some studies as a risk factor for AD. In addition,ApoE promoter polymorphisms differ slightly in the KET-04-001 populationcompared to random European sampling. This is also consistent with thewell know association of ApoE and AD.

Study Population

One hundred fifty-two subjects were randomized in this study. 140subjects completed at least one follow-up visit subsequent to Baseline,these subjects comprise the ITT population used for efficacy analyses.Treatment groups were well balanced for baseline characteristics.One-hundred thirty-five subjects (n=75 AC; n=60 PL) consented togenotyping for the APOE locus.

Ketosis

BHB levels were determined at Screening (pre-dose), Baseline, Day 45,Day 90 (pre and post-dose) and Day 104 (pre-dose). Post-dose levels weremeasured two hours after administration of investigational product.Screening BHB levels were within normal ranges and did not differbetween treatment groups (0.11±0.08 mM AC; 0.12±0.11 mM PL, p=0.590).Two hour post-dose, AC-1202 induced a significant elevation in serum BHBlevels on visit days Baseline, Day 45 and Day 90. At Baseline, subjectsreceived ½ dose of AC-1202 and mean serum BHB increased from 0.07 mM to0.14 mM, which was significantly different from the Placebo group(p<0.0001). Higher levels of BHB were obtained on full dose. Average2-hour post-dose BHB values in the AC-1202 group were 0.36 mM on Day 45and 0.39 mM on Day 90, both significantly different from Placebo group(p<0.0001). BHB levels were not different between AC-1202 and Placebogroups at any pre-dose sampling or after the 14 day washout.

ADAS-Cog

When ADAS-Cog scores were evaluated at Day 45 in the ITT population withLOCF, there was a significant effect of AC-1202 treatment on change'fromBaseline in ADAS-Cog scores. Subjects treated with AC-1202 showed a meanchange from Baseline of −0.177 points (negative score represents animprovement over Baseline), while those treated with Placebo showed amean change of 1.73 points (p=0.024). At Day 90, AC-1202 led to a mean−0.31 point change from Baseline in ADAS-Cog, whereas the Placebo groupshowed a mean 1.23 point change (p=0.077). On Day 104, after the twoweek Washout, there was no difference in the ITT population betweentreatment groups (p=0.405).

Genotype Effects on ADAS-Cog

Genetic influence of ketone body treatment was examined for a series ofgenetic markers in correlation with Day 90 change from Baseline inADAS-Cog. Analysis of the ADAS-Cog scores revealed that the carriagestatus of several of the markers tested demonstrated increased efficacyto AC-1202 treatment (See table 2).

IDE rs2551101. Subjects who were heterozygous at the rs2551101 locusdemonstrated a 4.06 point improvement in ADAS-Cog score when compared toplacebo (p=0.0068). Subjects who were not homozygous for the C alleledemonstrated a 2.74 point improvement in ADAS-Cog when compared toplacebo (p=0.0059).

IL1B rs1143627. Subjects who were homozygous for the T alleledemonstrated a 3.5 point improvement in ADAS-Cog when compared toplacebo (p=0.0145).

IL1B rs16944. Subjects who were homozygous for the C allele demonstrateda 3.5 point improvement in ADAS-Cog when compared to placebo(p=0.00145).

IGF1R rs229765. Subjects who were homozygous for the A alleledemonstrated a 7.3 point improvement in ADAS-Cog when compared toplacebo (p=0.0072).

IGF1R rs28401726. No significant effects were noted with this allele.

PON1 rs662. No significant effects were noted with this allele.

LDLR rs7259278. Subjects who were homozygous for the G alleledemonstrated a 2.56 point improvement in ADAS-Cog when compared toplacebo (p=0.0236).

LDLR rs2738447. Subjects who were homozygous for the C alleledemonstrated a 3.51 point improvement in ADAS-Cog when compared toplacebo (p=0.037).

LDLR rs1799898. Subjects who were homozygous for the C alleledemonstrated a 2.44 point improvement in ADAS-Cog when compared toplacebo (p=0.045).

LDLR rs11669576. No significant effects were noted with this allele.

BUCHE rs1803274. Subjects who were heterozygous at the rs1803274 locusdemonstrated a 4.29 point improvement in ADAS-Cog score when compared toplacebo (p=0.0133).

APOE rs448647. No significant effects were noted with this allele.

APOE rs405509. Subjects who were heterozygous at the rs405509 locusdemonstrated a 3.68 point improvement in ADAS-Cog score when compared toplacebo (p=0.0085).

APOE rs769446. No significant effects were noted with this allele.

TABLE 2 Treatment by Genotype Change in ADAS-Cog From Baseline at Day 90N for 2-way Anova AC- N for Treatment*Genotype Snp Genotype 1202 PlaceboP-value APOE rs449647 a 39 38 0.147 Het 17 11 0.14 t 3 3 0.4 APOErs405509 g 11 7 0.48 Het 26 27 0.0085 t 23 18 0.629 APOE rs769446 Het 56 0.405 t 55 46 0.0951 BUCHE a 2 Na rs1803274 g 40 39 0.541 Het 25 150.0133 IDE rs2251101 c 9 7 0.079 Het 22 25 0.0068 t 36 24 0.266 IGF1Rrs2229765 A 5 13 0.00719 G 27 18 0.156 het 34 25 0.826 IGF1R rs28401726C 52 48 0.0578 het 14 5 0.901 G 2 Na IL1B rs16944 C 29 27 0.0145 het 2817 0.845 T 6 9 0.479 IL1B rs1143627 C 6 9 0.479 het 28 17 0.845 T 29 270.0145 LDLR8 G 59 51 0.025 rs11669576 het 8 5 0.458 LDLR13 rs688 C 24 220.987 het 33 20 0.061 T 7 13 0.061 LDLR13 A 13 11 0.77 rs2738447 C 18 210.037 het 32 22 0.176 LDLR13 G 44 44 0.0236 rs7259278 het 17 8 0.403 T 22 0.974 LDLR 13 C 40 35 0.045 rs1799898 het 18 15 0.126 T 1 1 0.819 PON1rs662 A 28 26 0.12 G 6 7 0.239 het 32 23 0.73 IDE rs2251101 c/c 9 70.079 other 58 49 0.0059 AI program source: phg Tab 3

ADCS-CGIC and MMSE

When comparing AC-1202 and Placebo in the ITT population using LOCF,AC-1202 did not lead to a significant difference in the distribution onADCS-CGIC scores at any study.

TABLE 2 Treatment by Genotype: ADCS-CGIC Score at Day 90 2-way Anovageno- N for N for Treatment*Genotype Snp type Ketasyn Placebo PvalueApoe4 0 29 26 0.218 1 39 31 0.769 APOE rs449647 a 39 38 0.201 het 17 110.604 t 3 3 0.796 APOE rs405509 g 11 7 0.6868 het 26 27 0.5660 t 23 180.7090 APOE rs769446 het 5 6 0.441 t 55 46 0.274 BUCHE rs1803274 a 2 Nag 40 39 0.356 het 25 15 0.574 IDE rs2251101 c 9 7 0.789 het 22 25 0.569t 36 24 0.259 IGF1R rs2229765 a 5 13 0.350 g 27 18 0.871 het 34 25 0.585IGF1R rs28401726 c 52 48 0.299 het 14 5 0.292 g 2 Na IL1B rs16944 c 2927 0.839 het 28 17 0.492 t 6 9 0.437 IL1B rs1143627 c 6 9 0.437 het 2817 0.492 t 29 27 0.839 LDLR8 rs11669576 g 59 51 0.538 het 8 5 0.935LDLR13 rs688 c 24 22 0.436 het 33 20 0.662 t 7 13 0.295 LDLR13 rs2738447a 13 11 0.635 c 18 21 0.993 het 32 22 0.147 LDLR13 rs7259278 g 44 440.288 het 17 8 0.552 t 2 2 1 LDLR13 rs1799898 c 40 35 0.175 het 18 150.986 t 1 1 0.321 PON1 rs662 a 28 26 0.408 g 6 7 0.975 het 32 23 0.722IDE rs2251101 c/c 9 7 0.494 other 58 49 0.790 AI program source: phg Tab5

Significant treatment effects were found in change from Baseline in MMSEin Carriers of APOE rs405509 and PON1 rs662

TABLE 3 Treatment by Genotype: Change in MMSE From Baseline at Day 902-way Anova Geno- N for N for Treatment*Genotype Snp type KetasynPlacebo P-value Apoe4 0 29 26 0.369 1 39 31 0.704 APOE rs449647 A 39 380.595 het 17 11 0.424 T 3 3 0.277 APOE rs405509 G 11 7 0.929 het 26 270.067 T 23 18 0.037 APOE rs769446 het 5 6 0.504 T 55 46 0.834 BUCHErs1803274 A 2 Na G 40 39 0.892 het 25 15 0.413 IDE rs2251101 C 9 7 0.908het 22 25 0.206 T 36 24 0.111 IGF1R rs2229765 A 5 13 0.125 G 27 18 0.929het 34 25 0.844 IGF1R rs28401726 C 52 48 0.392 het 14 5 0.254 G 2 NaIL1B rs16944 C 29 27 0.846 het 28 17 0.943 T 6 9 0.879 IL1B rs1143627 C6 9 0.879 het 28 17 0.943 T 29 27 0.846 LDLR8 rs11669576 G 59 51 0.756het 8 5 0.762 LDLR13 rs688 C 24 22 0.240 het 33 20 0.365 T 7 13 0.468LDLR13 rs2738447 A 13 11 0.709 C 18 21 0.265 het 32 22 0.513 LDLR13rs7259278 G 44 44 1 het 17 8 0.903 T 2 2 0.859 LDLR 13 rs1799898 C 40 350.322 het 18 15 0.145 T 1 1 0.799 PON1 rs662 A 28 26 0.085 G 6 7 0.031het 32 23 0.287 IDE rs2251101 c/c 9 7 0.682 other 58 49 0.909 AI programsource: phg Tab 4Adverse Events Occurring before and after a Change in Dosing Protocol

During the first several months of the study, it appeared that arelatively high number of subjects were withdrawing from the study dueto gastro-intestinal adverse events, in particular, for diarrhea andflatulence. Following an assessment of the reasons given fordiscontinuation, it was recommended that study medication or placeboshould be mixed with a high protein drink (Ensure™) in order to improveinvestigational product tolerability. Clinical sites were informed ofthis decision and were subsequently provided with an ample supply ofEnsure for distribution to study subjects. Although specific data werenot collected regarding which subjects adhered to the new medicationmixing instructions, Accera had reason to believe that Ensure™ was madeavailable to all subjects who were on-study at that point in time orenrolled after the change.

To evaluate whether or not this change in study medication mixinginstructions appeared to improve product tolerability, an analysis ofsubject discontinuations was undertaken before and after the change wasundertaken.

Discontinuations Prior to the Change

Ten subjects [9 of 31 (29.0%) Treatment and 1 of 27 (3.4%) placebo]discontinued the study. During this time period, events within thegastro-intestinal system were the leading cause for withdrawal from thestudy. Within the GI system, 7 of 31 (22.6%) Treatment subjects and 1 of27 (3.4%) placebo subjects discontinued the study due to one or moreadverse events.

Discontinuations after the Change

Following the change in medication mixing instructions, the overallincidence of adverse events leading to study discontinuation declinedslightly in the Treatment group from 29.0% to 21.9%. Most notably, theincidence of gastro-intestinal events causing study withdrawal in theTreatment group declined from 22.6% to 12.5%.

Although the incidence of AEs leading to discontinuation declined inTreatment subjects after the change, the overall incidence of allreported AEs did not decline after this date. Twenty-one of 31 (67.7%)Treatment subjects and 13 of 27 (48.1%) placebo subjects experienced atleast one AE prior to the change. After the change, 47 of 64 (73.4%)Treatment subjects and 29 of 49 (59.2%) placebo experienced one or moreadverse events (data not shown).

All publications and patent applications cited in this specification areherein incorporated by reference as if each individual publication orpatent application were specifically, and individually, indicated to beincorporated by reference.

While the invention has been described with reference to exemplaryembodiments, it will be understood by those skilled in the art thatvarious changes may be made and equivalents may be substituted forelements thereof without departing from the scope of the invention. Inaddition, many modifications may be made to adapt a particular situationor material to the teachings without departing from the essential scopethereof. Therefore, it is intended that the invention not be limited tothe particular embodiment disclosed as the best mode contemplated forcarrying out this invention, but that the invention will include allembodiments falling within the scope of the appended claims.

The invention claimed is:
 1. A method of treatment for Alzheimer'sdisease, comprising the steps of: a. selecting a human patient having,or at risk of Alzheimer's disease; b. determining in the patient thepresence of at least one of the specific genotypes selected from thegroup consisting of: i. heterozygosity for C/T for Insulin DegradingEnzyme (IDE) rs 2251101 at relevant portion shown by SEQ ID NO:3, andii. absence of homozygosity for C/C of IDE rs 2251101 at relevantportion shown by SEQ ID NO:3; and administering to the patient having atleast one of the specific genotypes in (b a composition comprising aneffective amount of medium chain triglycerides (MCT) of the formula:

wherein the R1, R2, and R3 esterified to the glycerol backbone are eachindependently fatty acids having 5-12 carbon chains.
 2. The method ofclaim 1, wherein the method further comprises testing the patient forthe absence of ApoE4 genotype.
 3. The method of claim 1, wherein thecomposition is an oral composition which further comprises glucose. 4.The method of claim 1, wherein the composition is administered in anamount effective to raise the blood level of D-beta-hydroxybutyrate inthe patient from about 0.1 mM to about 50 mM.
 5. The method of claim 1,wherein the composition is administered in an amount effective to raisethe blood level of D-beta-hydroxybutyrate in the patient from about 0.2mM to about 5 mM.
 6. The method of claim 1, wherein the composition isadministered at a dose of about 0.05 g/kg/day to about 10 g/kg/day.